Download - Supracondylar fx
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EXT. CONFERENCEE X T. ว ส ว ตั ต ์ อ น ัน ต ์ณ ัฐ ศ ิริ
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PATIENT PROFILE
• ดญ. ไทย อายุ 5ปี6เดือน ภมูลิำาเนา อ.ครบุร ีจ.นครราชสมีา • วคัซนีครบมสีมุด พฒันาการสมวยั
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CHIEF COMPLAINT
• เจบ็ต้นแขนซา้ย 15ชม ก่อนมารพ.
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PRESENT ILLNESS
• 15ชม ก่อนมารพ. ขณะเล่นชงิชา้ พลัดตกลงมาสงู ประมาณ60ซม. ศอกซา้ยกระแทกพื้น เจบ็มาก ขยบัขอ้ศอกซา้ยไมไ่ด้ ปวด กำามอืได้ ขยบัขอ้มอืได้ ไมช่า ไมม่ีแขนสซีดีลง ไมม่แีขนอ่อนแรง ไมม่ขีอ้มอืตก อาการปวดไมดี่ขึ้น จงึพามารพ.
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PRIMARY SURVEY
• A: patent airway, can speak, no post C-spine injury, can flex neck• B: normal breathing pattern, no dyspnea• C: BP 107/60 ,CR <2secs, no external wound seen• D: pupil3mm RTLBE, E4V5M6 • E: no external wound, events as mentioned
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SECONDARY SURVEY
• A : no known allergy• M : no current meds• P : no known sx or any underlying disease• L : last meal 12.00• E : events as mentioned
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PHYSICAL EXAMINATION
• GA: A Thai girl conscious, not pale, no jaundice• HEENT: no pale conjunctiva, anicteric sclera• Heart : no active precordium, no cyanosis, CR<2secs, no heaving, no thrills,
normal S1S2, mo murmur• Lungs: no retraction, normal breathing pattern, clear sounds both lungs• Abdomen: not distend, normoactive bowel sound,soft, not tender, no
hepatospleenomegaly
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PHYSICAL EXAMINATION
• EXT: Lt Elbow : swelling, no external wound, no bruising, limit ROM Lt. elbow joint due to pain, radial pulses 2+,AIN intact(can do OK sign), Radial n. intact (no wrist drop)
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INVESTIGATION
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DIAGNOSIS
• Lt. supracondylar fracture Gartland II
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TREATMENTS
• At ER : on Posterior long arm splint• Operative : Closed reduction with percutaneous pinning
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S U PRAC O N DY L A R F RAC T U R ES
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EPIDEMIOLOGY• Epidemiology
– incidence• extension type most common (95-98%)
– demographics• occur most commonly in children aged 5 to 7• M = F
• Pathophysiology– mechanism of injury
• fall on outstretched hand
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PRESENTATION• Symptoms
– pain– refusal to move the elbow
• Physical exam– inspection
• gross deformity• swelling• bruising
– motion• limited active elbow motion
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ASSOCIATED INJURY• vascular injury (1%)
– rich collateral circulation can maintain circulation despite vascular injury• neuropraxia
• anterior interosseous nerve neurapraxia (branch of median n.)• the most common nerve palsy seen with supracondylar humerus
fractures• radial nerve palsysecond most common neurapraxia (close second)• ulnar nerve palsyseen with flexion-type injury patterns • nearly all cases of neurapraxia following supracondylar humerus
fractures resolve spontaneously, and therefore, further diagnostic studies are not indicated in the acute setting
• ipsilateral distal radius fractures
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IMAGING FILM AP,LAT ELBOW• posterior fat pad sign
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MEASUREMENT
• displacement of the anterior humeral line– anterior humeral line should intersect
the middle third of the capitellum– capitellum moves posteriorly to this
reference line in extension type fracture
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ALTERATION OF BAUMANN ANGLE • normal is 70-75 degrees, but best judge is a
comparison of the contralateral side• deviation of more than 5 degrees indicates
coronal plane deformity and should not be accepted
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CLASSIFICATION
GARTLAND CLASSIFICATIONTYPE I Nondisplaced, beware of subtle medial comminution leading to
cubitus varusTYPE II Displaced, posterior cortex intactTYPE III Completely displacedTYPE IV Complete periosteal disruption with instability in flexion and
extension
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GARTLAND I
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GARTLAND II
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GARTLAND III
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GARTLAND IV
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TREATMENT• Nonoperative
– long arm posterior splint then long arm casting with less than 90° of elbow flexion techniquetypically used for 3-4 weeks and maybe followed for additional time in removable long arm posterior splint
– Indications : • Type I (non-displaced) fractures • Type II fractures that meet the following criteria
– anterior humeral line intersects the anterior half of capitellum– minimal swelling present– no medial comminution
• Operative– closed reduction and percutanous pinning
• indications : Type II and III supracondylar fractures
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COMPLICATION• Pin migration
– most common complication (~2%)• Infection
– occurs in 1-2.4%– typically superficial and treated with oral antibiotics
• Cubitus valgus– caused by fracture malunion– can lead to tardy ulnar nerve palsy
• Cubitus varus (gunstock deformity) – caused by fracture malunion
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REFERENCE
• http://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric